Parkinson's Disease


Parkinson’s Disease


Parkinson’s disease is a common ailment affecting the elderly. There is a lack of dopamine in the brain leading to slowing down of movement. It manifests usually in the 6th or 7th decade with slowness (bradykinesia), a resting tremor( seen one sided in the arm or foot at rest), shuffling or slow gait, soft voice, rigidity or stiffness, falls due to poor balance, decreased facial expression (mask like facies) and a generalized sense of weakness. In addition many also complain of constipation, cramps and problems with excessive movements during sleep (REM or Rapid Eye Movement sleep behavior disorder). Rarely alterations in the sense of smell and smaller hand writing (micrographia) is noted. Freezing episodes and excess body movements related to dopaminergic medications ( dyskinesias) are common. 

Though various etiologies have been proposed environmental factors and genetics seems to play an important role in this disease. The basal ganglia, located in the center of the brain is an important part of the circuit involved in coordinating and fine tuning movement. The surface of the brain (cortex) has many nerve cells ( neurons) that initiate voluntary movement and connect with areas in the basal ganglia ( globus pallidus, putamen and striatum) to modulate motion. An area in the upper brainstem (midbrain) has an area ( the substantia nigra) where dopamine, a neurotransmitter, is produced. In parkinson's disease this area under produces dopamine ( hence the basal ganglia functions poorly) and contributes to slowness or bradykinesia.


Many diseases may present with the similar symptoms and warrant further evaluation as listed below:


Parkinsonism may be present when the tremor is not at rest and presents bilaterally. These include multiple rare diseases which your physician will be able to diagnose eg: Lewy body dementia, multisystem atrophy, supranuclear palsy, etc.


Urinary incontinence and dementia with shuffling gait may be seen in Normal Pressure Hydrocephalus (NPH) a brain condition due to excess spinal fluid that may improve with brain shunt devices.


Strokes may present with similar symptoms including rigidity and slowness, poor gait.


Neuromuscular causes of weakness including muscle diseases, myasthenia, myopathy, etc may present with weakness.


Peripheral neuropathy may cause imbalance and falls.






Treatment of PD:


Neurology Consultation is helpful. (click here for neurologists in your area).


Consider imaging either Cat Scan (computed tomography or CT brain) or MRI (Magnetic Resonance Imaging) brain imaging.  (click here to find out imaging facilities/ imaging costs in your area). Blood tests (Lyme titers, Sedimentation rate in older patients, RPR and TSH, etc) may be indicated. (click for lab facilities and costs of testing). 


Medications your physician may prescribe include carbidopa-levodopa (sinemet), pramipexole (mirapex), ropinirole (requip), rapid release carbidopa-levodopa (parcopa), entacapone ( comtan), apomorphine ( apokyne) for freezing episodes, rasagiline (azilect), selegiline, and for essential tremors – mysoline ( primidone), propranolol ( inderal). For excessive writhing movements or dyskinesias related to dopaminergic medication side effects amantadine (symmetrel) may be helpful.

Nausea related to sinemet may be alleviated with carbidopa (lodosyn) 25mg tid or even a trial of a simple device known as SEA BAND (CLICK HERE TO VIEW) a wrist band like device may be helpful.



For difficult to control symptoms and on and off phenomenon, surgery with DBS or Deep Brain Stimulation is also available. DBS is a pacemaker device which stimulates via a pliable electrode wire embedded in the deep brain structures, either the globus pallidus or sub thalamic nucleus, to facilitate movement. It helps the tremors, slowness and rigidity and is a safe option in addition to medications.

 Click Here for more information on Deep Brain Stimulation DBS.


Tips for Parkinsons Disease


Exercise daily and practice walking.


Avoid taking carbidopa-levodopa with high protein meals. The intestine absorbs protein in preference to the medication and this may contribute to lower efficacy for that dose.


Avoid non compliance due to the risk of falls from off periods (periods when medication effect is low)


Cramps suggest low dopamine levels and may warrant more frequent dosing requirements


Time the effects of the medications, the time it wears off and report it to your physician to allow adjustment.


There is no clear evidence that vitamin E or Coenzyme Q reverses the course or improves outcome in medical trials. Azilect may have some protective properties but evidence is still weak at best.


Adequate night lights and striped carpets or striped liners may be helpful in slow gait.


For night time dosing consider extended release carbidopa levodopa


Constipation may benefit from sodium docusate (colace) stool softeners. A glass of prune juice daily helps with the bowel movement. Rarely senokot, magnesium citrate may also be helpful.  Read More on how to manage constipation..


Memory problems in parkinson’s patients may respond to medications used for alzheimers.


REM behavior sleep disorder may respond to Clonazepam which induces a deeper stage of sleep preventing falls from bed.


A multivitamin daily is helpful. A healthy diet and healthy level of activity is recommended.